By Daniel J. DeNoon
WebMD Medical News

Reviewed By Louise Chang, MD

How important is health insurance to Americans? A Kaiser Foundation poll released today shows that health care is the fourth most important issue in the 2008 election �?only recently bumped from third place by rising gas prices.

Lack of Health Insurance Growing?

Are more Americans uninsured than in previous years? That depends on how you measure it. The CDC interview data suggest that the uninsurance rate has been relatively stable. But a 2006 Kaiser Foundation report, based on U.S. census data, suggests that the number of Americans without health insurance is steadily growing.

"The number of uninsured Americans has been growing," Kaiser researcher Catherine Hoffman, ScD, tells WebMD. "Even in the mid-1990s, when the economy was booming, we saw the number of uninsured Americans grew by about a million a year. And that is because there was never any control over health costs. We just don't have a solution."

High costs, Hoffman says, make private insurance more costly �?and decrease employer-sponsored insurance, the main source of insurance for over 60% of Americans under age 65.

The CDC reports show that the states with the highest uninsured rates have the lowest rates of private insurance coverage. Ominously, the percentage of Americans who have private health insurance is dwindling.

"Data from the current survey does show the percentage of the nonelderly population that is uninsured is increasing largely because of the decline in employer-sponsored insurance," Hoffman says.

However, even though about 9% of kids under age 18 lack any health insurance, fewer kids are uninsured thanks to government-funded State Children's Health Insurance Program (SCHIP) coverage. Even so, the percentage of children without health insurance ranged from 3.7% to 18.7% among the states.

"Were it not for public coverage in the last decade, many, many more children would be uninsured," Hoffman says. "We have managed to put a dent in the uninsured problem for children through expansion of public programs. Those same programs have not expanded for adults."

Uninsured vs. Underinsured

Is the health insurance that people have enough to meet their needs? Neither the CDC nor the Kaiser report directly addresses this issue. The problem is that it's simple to say who has and doesn't have health insurance, but it's hard to know whether you have adequate insurance until you need it.

"Some researchers say anyone who is insured and has trouble paying medical bills is underinsured," Hoffman says. "Others say if medical bills come to more than 10% of an insured family's income, they are underinsured. And some people may just have catastrophic coverage, and only when something like an emergency appendectomy wipes out their savings do they realize they are underinsured."

The CDC survey found that in 2007, 17.5% of insured Americans under age 65 had a high-deductible health plan, and nearly 17% had a flexible spending account in which they set aside pre-tax dollars for medical expenses.

"This tells you that 17% of people with insurance recognize they are going to face those out-of-pocket medical expenses and have to save for it," Hoffman notes.

In the June issue of the journal Health Affairs, Commonwealth Fund researcher Cathy Schoen, MS, and colleagues estimate that 25 million under-65 adults with health insurance were underinsured in 2007 �?a 60% increase since 2003.

"The coverage erosion for adults with incomes 200% to 299% of poverty is now putting middle- as well as low-income families at risk," Schoen and colleagues warn.